Nutrition

Getting proper nutrition is an important part of healthy living for every person. This is especially true for people with diabetes. Our bodies require a balanced daily diet to get all the nutrients and calories we need to function at our best. However, with diabetes something goes wrong with the way our body processes the food we take in, interfering with our ability to use that food for energy and to maintain our health. This includes knowing what foods to include in our diet, what foods to eat less of, and how foods will affect blood glucose and other important health measures, such as blood pressure, lipids, and weight.

Guidelines for healthy eating

You should aim to eat a healthy, balanced diet that provides basic vitamins, nutrients, and calories to support requirements for energy and fitness. For guidance on healthy eating for the general public, the US Department of Agriculture (USDA) offers online information at www.choosemyplate.gov, based on 2010 Dietary Guidelines issued by the USDA.

2010 Dietary guidelines stress the importance of maintaining a balance of caloric intake over time to achieve and maintain a healthy weight and to focus on intake of nutrient-dense foods and beverages. This includes limiting sodium and avoiding foods that contain too much fat, sugar, or refined grains. A healthy eating plan emphasizes consumption of “vegetables, fruits, whole grains, fat-free or low-fat milk and milk products, seafood, lean meats, eggs, beans, peas, and nuts and seeds.”1,2

Many of the same basic healthy eating principles recommended by the USDA apply to people with type 2 diabetes. In fact, similar to the USDA 2010 Dietary guidelines, the American Diabetes Association (ADA) recommends:3

Improving overall nutrient intake by focusing on carbohydrate sources including vegetables, fruits, whole grains, legumes, and milk over other carbohydrate sources, including those with added fats, sugars, or sodium.

Limiting the amount of dietary saturated fat, cholesterol, and trans fat intake to reduce cardiovascular risk. Saturated fats should comprise no more than 10% of daily caloric intake.

Increasing intake of omega-3 fatty acids (found in fatty fish) due to their beneficial effect on lipids and their ability to prevent heart disease.

Eating at least as much dietary fiber and whole grains as is recommended for the general public.

Reducing consumption of sodium to less than 2,300 mg/day (greater reductions may be appropriate for individuals with high blood pressure).

Basics of nutrition

If you want to eat well, it helps to understand some basics about nutrition, including what the basic macronutrients are (carbohydrates, protein, and fat) and what calories are, and how to put this basic knowledge of nutrition to work when you are food shopping and preparing meals.

What is a calorie?

Calories are simply a measurement of the amount of energy in food. Nutrients like carbohydrates and protein have the same amount of calories or energy per gram (4 calories per gram). Fats have about two times the amount of calories per gram (9 calories per gram). Other sources of calories include alcohol, which has 7 calories per gram, and fiber, which has 4 calories per gram. One important fact to keep in mind about the calories you eat is that the calories your body doesn’t use right away are stored by the body as fat (triglycerides). This is why, regardless of the foods you get your calories from, if you take in more than you burn, you will gain weight in the form of fat. This is also why you burn fat (stored calories) when you restrict your calorie intake to less than you require for your daily energy needs.

Food groups

There are three macronutrients that we get our calories from. They are:

Carbohydrates

Protein

Fat

Think of foods as packages of varying amount of carbohydrate, protein and/or fat. Some, like whole milk, contain all three. Others, like fruit contains mainly carbohydrate with a bit of protein. Margarine or butter contains calories mainly from fat.. Foods also contain varying types and amounts of vitamins and minerals and fiber. To illustrate the nutrient content of a typical food, let’s look at broccoli. According to the USDA National Nutrient Database (at http://ndb.nal.usda.gov/ndb/search/list), a cup of chopped raw broccoli has 31 calories, with approximately 3 grams of protein, 6 grams of carbohydrates, and 0.5 grams of fat. It also contains 2 grams of fiber.

The percent of calories you need from carbohydrate, protein and fat will depend on personal factors, such as whether you are overweight and/or at risk for cardiovascular disease. In general, according to USDA Dietary Guidelines, adults should get 45% to 65% of daily calories from carbohydrates, 20% to 35% of daily calories from fat, and 10% to 35% of daily calories from protein.4 Work with your registered dietitian (or diabetes educator) to determine which percentages of these macronutrients your daily diet should include. In terms of how much carbohydrates, protein, and fat you should eat, there are no “ideal” amounts for every person with type 2 diabetes. The right amounts of these macronutrients will be determined according to your individual needs.

Carbohydrates

Carbohydrates are found in foods such as vegetables, fruits, grains (bread, pasta), legumes, cereals, and dairy products. Carbohydrate is the main macronutrient transformed through digestion into glucose, which is the main and major source of energy for the body. In fact, blood glucose increases rapidly after we eat a food rich in carbohydrates, in as little as 15 minutes. However, not all carbohydrate-containing foods are equal. Some have more nutrients, including fiber, vitamins, and minerals, than others.5

How easily a carbohydrate-containing food is digested affects how quickly it will be transformed into glucose. Generally, cooked foods are digested more quickly than raw foods. Foods that require more chewing, such as corn and certain vegetables, will breakdown more slowly. The quantity and quality of the carbohydrates you consume determines how they will affect your blood glucose. Carbohydrate-containing foods can be categorized qualitatively by their glycemic index and there is some evidence that the glycemic index of a food shows how it will impact blood glucose.

The other important factor when comparing carbohydrates is how they are eaten in combination with other nutrients. Adding fat to a food that contains carbohydrate (one good example is a pastry, which combined flour and fat, in the form of butter or shortening) or eating carbohydrates in combination with high-fat foods tends to slow down absorption of the carbohydrate. This will delay the effect that the carbohydrate has on blood glucose.

So, what is a lesson that we can take away from this basic information on carbohydrates as a food group? Let’s look at sugar. We thought at one time in the past that you should avoid sugar altogether if you had diabetes. However, this is really not the case anymore. You can eat sugary foods, such as candy, but these foods tend not to have much other nutritional value (no protein, fiber, or vitamins or minerals). So, if you eat sugary sweets or desserts, you should do so in moderation, because they’ll take up a lot of calories and won’t give you much nutritional “bang for your buck”.

Protein

We all require protein to keep our bodies healthy. This important macronutrient is responsible for building cells and tissue. Protein takes part in the continual process of repairing the body. Protein can be used for energy, too. However, this typically doesn’t happen unless we are not consuming carbohydrates and we don’t have stored fat to burn. Foods that contain protein include meat, poultry, seafood, eggs, and dairy products. Many of these same foods contain fat, some of which can pose problems for our health (such as cardiovascular disease), which is why getting protein from low-fat and fat-free dairy and lean meats is often recommended. Vegetables, legumes (peas, beans, lentils, soybeans), and grains also contain protein (as well as carbohydrates) and are also low in fat. One other source of protein is nuts.5

Fat

Fat is an important part of our diets. We depend on a certain amount of fat for fuel and energy and require fat to maintain the health of our bodies on a cellular level. However, consuming too much fat, particularly certain kinds of fat, can be dangerous for our cardiovascular health because these fats can enter the blood stream and build up on the interior walls of blood vessels.

There are two basic groups of fats in foods, saturated fats and unsaturated fats. Polyunsaturated fatty acids and monounsaturated fatty acids are considered “good fats”. Omega-3 fatty acids are one type of polyunsaturated fat found in fatty fish and other foods including nuts, seeds, and vegetable oils. Monounsaturated fats are found primarily in vegetable food sources, including olive oil and canola oil. 5

Saturated fatty acids which come mostly from animal products, such as red meat and dairy products, are considered “bad fats” in our diets. We want to limit the amount of saturated fats we consume. Trans fatty acids (trans fats) are a type of saturated fat that occurs naturally in some foods, such as animal products. Synthetic trans fats can be created through a process called hydrogenation which is used to harden oils or make fats more solid. These synthetic trans fats are used to make many processed foods. Hydrogenated or partially hydrogenated oils, which are found in margarine, are trans fats5

Unhealthy fats5

Sources: margarine sticks, shortening, french fries (fast-food), many processed foods such as chips and crackers, cookies and cakes

Any product that contains hydrogenated or partially hydrogenated oil

LDL cholesterol

Sources: meat, poultry, egg yolks, dairy products

Research over the past several decades has taught us about different types of dietary fats and their role in cardiovascular disease and other diseases. A pattern of eating that is low in saturated fats (including trans fats) is recognized as important for cardiovascular health. Saturated fats should comprise no more than 10% of daily caloric intake. Instead of saturated fats, our daily fat intake should include healthier fats, especially monounsaturated fats and also polyunsaturated fats that protect against heart disease and contribute positively to overall health.

How to reduce fat from meat and other sources in your diet5

Choose lean cuts

When you shop for meat, look for words including “loin,” “round,” “lean,” “choice,” and “select.”

Remove extra fat

Trim visible fat and remove skin from poultry

Prepare without frying

Broil, roast, grill, steam, or poach

Avoid frying

Limit portion size

Make sure your meat portions are 3-5 ounces per meal (no more than a deck of cards)

Half of a skinless, boneless chicken breast is about 3 ounces

Remove fat from broths, soups, and drippings

Chill in the refrigerator, which allows fat to separate and solidify so that it can be removed

Avoid fried foods

Always select broiled or baked foods instead of fried foods

Limit egg yolks

You should limit the number of egg yolks you eat to 4 per week

Vitamins and minerals

In addition to the three main macronutrients, vitamins and minerals are an important part of daily nutrition. If you have a balanced and diverse pattern of eating, rich in vegetables, fruits, whole grains, and dairy, and get a sufficient amount of calories, you’ll get most of the vitamins and minerals you need naturally. However, talk to your healthcare provider or dietitian about whether you should take a supplement to increase your intake of certain vitamins and minerals. This is especially important if you are a woman who is pregnant or planning to become pregnant, or if you are over a certain age and at risk for osteoporosis.

Shopping for healthy foods

Now that you know the basics about different macronutrients and have a general idea of the kinds of foods a healthy pattern of eating should include, it’s time to put that knowledge to work. There is no better place for this than the grocery store. Even though it’s fun to eat out from time to time, there is no better way to eat healthy than to prepare your own meals. This can be difficult, especially if you are used to eating out often. But work with your dietitian to plan some meals (determine the ingredients) and then put your shopping list together and head to the store.

When you’re shopping for food, it helps to have a few rules of thumb to help you select the best ingredients for your healthy diet.

Vegetables and fruits. The ADA recommends improving overall nutrient intake by focusing on carbohydrate sources including vegetables and fruits (as well as whole grains, legumes, and milk) over other carbohydrate sources. This makes the fresh vegetable and fruit section of the grocery store the key section for your healthy eating plan and the place where you’ll find the most nutrition for you buck. Remember, fresh vegetables and fruits are a great source of dietary fiber and a high amount of fiber (25-30 grams per day—most American only about 14 grams per day) may be beneficial for blood glucose control.

You can also purchase canned vegetables and fruits. However, with canned vegetables and fruits, check the Nutrition Facts label and ingredient list to see how the product is canned and whether sugar (especially in the case of fruit) or sodium (in the case of vegetables) is added. If you buy canned vegetables with salt added, make sure you rinse the contents of the can well to wash away extra sodium.5

As far as fruit goes, other options in place of fresh fruit include dried or frozen fruit. Always check to see if sugar has been added and try to find products that contain no added sugar. Fruit juice, made from 100% juice with no sugar added, provides a good source of some nutrients. A problem when you purchase fruit juice away from home is the portion size. Portions often exceed a 12-oz serving and 45 grams of carbohydrate. Check the Nutrition Facts label to see how many grams of carbohydrate (and calories) are contained in a serving of fruit juice. Also, in diabetes meal planning, a serving of juice is often considered 4 oz, while the Nutrition Facts label considers a serving to 8 oz.

Grains. In general, when you shop for grains and products made from grains (bread, pasta), always try to select whole grains. Breads and pastas will often have packaging that says “whole grain”, but you should also be able to find this information in the ingredient list. If it contains whole grain it will say “whole wheat” or “whole grain”.5

When selecting dry cereals, pick products with whole grains first on the list of ingredients. (Ingredients are listed in descending order according to their weight, so the ingredients at the top of the list make up most of the weight of the packaged food product.) Also, make sure that your cereal selection says on the Nutrition Facts label that a single serving contains 3 or more grams of dietary fiber, 1 gram or less of fat, and 5 grams or less of sugar.

Crackers and snack foods also often contain grains. However, they also tend to be highly processed and can contain a dizzying list of ingredients with not much nutritional value. Again, look for products that show whole grains first on the ingredient list. Products such as air-popped popcorn (without added cheese or butter) or pretzels (which usually contain refined flour) are low-fat snacks. Sodium (including salt) is another important consideration when it comes to snacks. As a rule of thumb, make sure that your snacks contain no more than 400 mg of sodium per serving.

Meat. When you shop for red meat, look for the “grade” of the meat. Meat is graded, in part, according to fat content. Select lower-fat cuts such as “Choice” or “Select”, rather than “Prime” (this is a high-fat cut).5

When you shop for lunch meats or cold cuts, select lean or fat-free products and make sure that the product is low in sodium. Look on the Nutrition Facts label and make sure that the product is in the range of 30-55 calories per ounce and no more than 3 grams of fat per ounce.

Chicken or turkey breasts (without the skin) are the lowest-fat parts of poultry. If you buy a whole chicken (or turkey), you can reduce the fat content by up to 75% and the cholesterol content by 12% when you remove the skin before cooking. Ground turkey is a good lower-fat replacement for ground beef. Select ground turkey that has a fat content by weight of less than 7-8%. Look at the Nutrition Facts label and if it doesn’t list percentage fat content, divide the total grams per serving size by the grams of fat per serving to get the percentage fat content. Sometimes with ground turkey, skin is included when the meat is ground and this can result in a higher fat content.

Be aware that processed meat products made of turkey or chicken, such as salami, bologna, hot dogs, sausages, and bacon, can contain quite a bit of fat. Always look at the Nutrition Facts label and select products with less than 30% fat.

Seafood. Seafood is a good source of nutrition, including protein and fat. Often the fat contained in cold water fish is rich in omega-3 fatty acids, a type of polyunsaturated fat that is beneficial for cardiovascular health. When you shop for seafood, avoid items that have a fishy smell. Signs of freshness in seafood include clear eyes (for whole fish), red gills, and shiny skin. If you are purchasing canned seafood, make sure you select low-sodium products, such as fish packed in water. With products that are canned in oil, make sure to rinse the oil off before using.5

Dressings. Select fat-free or reduced-calorie salad dressings and make sure that you consult the Nutrition Facts label to calculate how many carbohydrates these products will add to your diet.

Soup. Select fat-free or reduced-fat and low-sodium soups. When you prepare soup, use a low-fat or fat-free milk or water.

Frozen desserts. There are more low-calorie and low-fat options now than ever before among frozen desserts. In general, you should select products made from low-fat yogurt or low-fat or fat-free ice cream. Frozen juice products (without added sugar) are also available and have as few as 70 calories per serving. A rule of thumb for fat content in frozen desserts is that there should be no more than 3 grams of fat per 4-ounce serving (this is roughly equivalent to 1/2 cup). Desserts that contain coconut or palm oil, cream of coconut, or coconut milk should be avoided, as these oils are high in trans fats or saturated fats.5

Margarine and oil. When you shop for cooking and other oils, the healthiest options are olive, canola, soybean, safflower, sesame, sunflower, or corn oils. If you are planning to sauté something, non-stick vegetable cooking spray is a good way to cut down on the use of cooking oil. In selecting margarine, make sure the brand you select has liquid oil (olive oil, canola oil, safflower oil) first on the ingredient label and is made without trans fats.

Cakes and cookies. When shopping for baked goods, such as cakes and cookies, one rule of thumb is to select brands that have no more than 3 grams of fat per 100 calories (you’ll find this information on the Nutrition Facts label). Steer clear of baked goods that contain palm, coconut, and hydrogenated oils.

There are many different cake mixes available that are low-fat and low-cholesterol (these often use a substitute for eggs), or have directions for making low-fat variations. Angel food cake is an example of a cake made without fat and cholesterol.

Understanding the language of nutrition

The US FDA has specific definitions for each nutrition claim and understanding these claims can make you a more informed and better shopper.

Understanding nutritional claims5

Calorie free

Less than 5 calories per serving (or other designated amount)

Low calorie

40 calories or less per serving

Light or lite

One-third less calories, 50% less fat, or 50% less sodium than regular version

Less or reduced

At least 25% fewer calories or other ingredients (eg, fat or sugar) than the regular product

Cholesterol free

2 mg or less of cholesterol and 2 grams or less of saturated fat per serving

Low cholesterol

20 mg or less of cholesterol and 2 grams or less of saturated fat per serving

Low fat

3 grams or less of fat per serving

Fat free

Less than 0.5 grams of fat per serving

Low saturated fat

1 gram or less of saturated fat per serving

Saturated fat makes up no more than 15% of total calories

Low sodium

140 mg or less of sodium per serving and per 100 grams of food*

Very Low sodium

35 mg or less of sodium per serving and per 100 grams of food

Sodium free or salt free

Less than 5 mg of sodium per serving

Light in salt

50% less sodium than regular version

Sugar free

Less than 0.5 grams of sugar per serving

Dietetic

No standard meaning, but indicates that something (sugar, salt, fat, cholesterol) has been changed compared to regular version

Natural

Specific meaning only with meat and poultry products, where it indicates that chemical preservatives, hormones, and other similar substances have not been added

Not restricted in meaning when it appears on other types of foods

Fresh

Raw food that has not been frozen, heat processed, or preserved in any way

*Includes sources of sodium other than table salt, such as monosodium glutamate (MSG), sodium bicarbonate (baking soda), and sodium nitrate.